It never fails. It's the middle of the night on a Saturday. Suddenly, you've overcome with a sharp pain in your stomach. You wonder if it might be gas, but then you begin to feel nauseated and feverish. You try to ride it out, but the pain just won't let up. Eventually, you give in and ask a loved one to take you to the ER.

As you walk through the sliding glass doors, you see an ocean of malcontent faces. You walk up to the sign-in desk and are immediately given a clipboard and asked to have a seat. You wait for seems like an eternity, finally get to tell the nurse your story only to be told to have a seat outside again. "Someone will be with you shortly," she says.

Working in emergency medicine has taught me a lot about what it's like to be a patient. Here are some of the things I've learned over the years, things every patient should know.

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Second Opinons

In the ER, radiology images are almost always sent for overread. While ER physicians are completely capable of interpreting x-rays, CT scans and ultrasounds, a second opinion is requested by a radiologist, or doctor whose specialty is reviewing these images and helping formulate your diagnosis. This radiologist may or may not be onsite, and is typically given at least an hour to respond to the overread request and submit a written report. Depending on the nature of your illness or injury, the ER physician may wait to discharge you until this report has been received.

Why It Takes So Long

After you sign in, the first person you'll speak with in the emergency room (also called the emergency department or ED) will be the triage nurse.

The word triage comes from the French word trier, meaning "to sort." In the ED, there are a finite number of resources (physicians, mid-level practitioners, nurses, patient treatment rooms, etc.). The job of the triage nurse is to prioritize patients as they sign in and decide whose acuity (the seriousness of the illness or injury) is the highest.

All ER patients are assigned one out of a possible five priority levels. All of the Priority One patients are seen first. Then, the Priority Two, etc. If you are assigned a relatively low priority during triage (cough, flu-like symptoms, rash, etc.), as you are waiting to be taken back to the treatment area, those who sign in with more complex, serious conditions will be prioritized ahead of you. What you may not see while sitting in the waiting room is the ambulance traffic. Patients arriving by ambulance take priority over everyone else.

ER nurses are typically assigned three or four patients at a time with varying levels of acuity. However, there may only be one or two physicians on duty for the whole department. Charting a patient's history, physical exam, medications, entering medication, diagnostic and procedural orders, reviewing and acknowledging results and typing discharge orders, prescriptions and patient education and referral information is a lengthy process.

Busier facilities may have an ER "fast track." This section of the department is designated for the treatment of minor emergencies, and while it will still be as expensive as a full ER visit, it can dramatically reduce the amount of time you spend in the department. Some fast tracks have separate entrances and sign-in desks.

ERs Can Discharge You Without Treatment

It's a common misconception that emergency room treatment is free of charge for those without insurance who are unable to pay.

Technically, it is not always "against the law" for ERs to turn patients away. The Emergency Medical Treatment and Labor Act (EMTALA) only requires Medicare-participating emergency rooms to stabilize and treat life-threatening conditions regardless of the patient's ability to pay. Not all hospitals participate in Medicare. While non-participating hospitals observe EMTALA as a general rule, they are not legally required to do so. Each hospital's EMTALA policy should be prominently displayed within view of the sign-in desk.

If you are uninsured and unable to pay for your visit, an ER physician will perform a Medical Screening Exam (MSE) to determine whether your condition is life-threatening. This may or may not include diagnostic testing such as radiology (x-rays, CT scans or ultrasounds) or laboratory testing. EMTALA and hospital policy leave this determination up to the individual physician. Typically speaking, any testing performed as part of an MSE may be free of charge. Indigent patients whose conditions do not meet EMTALA criteria may be discharged without treatment.

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Minor Emergencies Are Just As Expensive

When it comes to deciding what amount to bill you or your insurance, an emergency room physician has a limited number of options. The complexity of the history and physical, the amount of time he or she spends with you, the complexity of medical decision making in forming your diagnosis and determining an appropriate course of treatment will sort your visit into one of five categories. The difference between the charges associated with each billing level is minimal.

Many hospitals offer payment plans and prompt pay discounts. If you are uninsured or have a high deductible, paying out of pocket the day of your ED visit can sometimes save you up to 80%. Larger hospital systems sometimes also have charitable works programs which forgive debt based on financial need. You may be required to apply separately for these programs and be asked to provide supporting documentation (pay stubs, tax returns, etc.).

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Micro-Hospitals

Some freestanding ERs are equipped to provide inpatient services, short-term hospital stays for observation and treatment. These "micro-hospitals" are slightly larger than typical freestanding ERs, but still nowhere near as large as traditional hospitals.

Micro-hospitals typically have more than one entrance: the entrance to the emergency department and a separate entrance to the inpatient section. They are also typically two-story, and affiliated with a larger hospital system within the city.

Freestanding ERs Are Not Urgent Cares

The latest trend in emergency medical care is the freestanding or stand-alone ER. At first glance, these relatively small buildings may look like urgent care clinics because they are not attached to multi-level hospitals. However, freestanding ERs provide all of the same services as a hospital-based emergency department. They are open 24/7, staffed by board certified emergency physicians and specially trained nurses and have on-site radiology and laboratory services. As such, they bill at the same level as a hospital ER.

If you are unsure whether you are about to walk into an urgent care center or freestanding ER, look for these three things:

"Emergency" Signage—Urgent care centers are generally open late, but may not be open 24/7. If you see any sign which advertises 24-hour emergent care, you may be at a freestanding ER.

Financial Disclosure—One of the forms you will be asked to sign before triage is a financial disclosure, or Assignment of Benefits (AOB), which permits the ER to bill your insurance on your behalf. At a freestanding ER, this form will alert you that the treatment you receive will be billed as an emergency room visit and that you will be responsible for any portion not covered by your insurance provider.

Radiology—Many urgent care centers have on-site x-ray capabilities. However, they do not offer computerized tomography (CT) scans. If the facility you are at has CT capability, you are most likely at a freestanding ER.

Freestanding ERs have less overhead than hospital-based ERs. With minimal staff on-site and no hospital to support, freestanding ER vists (while still more expensive than urgent care visits) may be less expensive than hospital-based ER visits.

This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

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